The early days of spinal tumour surgery.
In numerous examples in this series of essays on 'The Early
Days of ...' there is argument and debate about who should be given
the credit for introducing a particular major advance in treatment.
However, in the story of the management of tumours involving the spinal
cord, there is no doubt at all about priority; the surgeon was Victor
Horsley and the date was June 1887! The patient was a Captain Gilbey, a
business man and a retired Army officer. In 1884, shortly after his
wife's death following a road traffic accident, he developed severe
upper thoracic back pain. He was seen over succeeding months and years
by numbers of specialists, whose diagnoses ranged from an aneurysm to
neurasthenia, and whose treatments included advice to take a long sea
voyage, to have Turkish baths and to take the cure at the medicinal
baths at Aix-la-Chapelle. His various medical advisors thought his
condition to be functional, even though he was gradually losing
sensation and movement in his legs and trunk, was having considerable
difficulty in passing his urine and was now requiring morphia for the
KEYWORDS Spinal tumour / Spinal cord
(Care and treatment)
Backache (Risk factors)
Tumors (Care and treatment)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Dec, 2011 Source Volume: 21 Source Issue: 12|
|Topic:||Event Code: 310 Science & research Canadian Subject Form: Tumours; Tumours; Tumours; Tumour removal; Tumour removal|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Fortunately, in June 1887, the patient was referred to William
Gowers, physician to the recently opened National Hospital for Nervous
Diseases, in Queen Square, London. By now, the diagnosis was barn door
to an experienced observer--paralysis of the legs, with flexor spasms,
sensory loss below the mid thoracic level, agonising pain at this level
on the least movement and a distended bladder--obviously involvement of
the thoracic spinal cord. No deformity to suggest tuberculosis of the
spine, so the disease must be a tumour compressing the spinal cord.
Up to that time, no patient had survived this malady, but Gowers himself in his text book, 'Manual of Diseases of the Nervous System', had suggested that removal of a spinal meningeal growth would be 'not only practicable but actually a less formidable operation than the removal of intracranial turn ours'.
Victor Horsley, then aged 30, who had been appointed as assistant surgeon to the National Hospital just the year before was asked to see the patient and operated the same day.
Under chloroform anaesthesia, and in the prone position, the spines and laminae of the thoracic vertebrae 4, 5 and 6 were resected (laminectomy), and the dural sac exposed and opened--nothing abnormal was found. Further exposure of the next lamina above revealed a dark bluish almond- shaped mass deep to the dura, compressing the spinal cord and forming a deep depression in it--a benign, slowly growing meningioma. It was completely removed.
In three weeks, the patient had return of sensation to light touch in his legs and had regained control of his bladder. Slow but steady recovery took place. By November the patient was walking with sticks and by February of the next year he was fully recovered and back to work. Gowers and Horsley reported the case in the Medico Chirurgical Transactions of 1888 and the surgical treatment of spinal tumours was born! In fact, the patient lived for another 20 years before dying of an unrelated condition.
Remember that this patient's management was carried out entirely on clinical diagnosis; there was absolutely no laboratory or imaging aids available at that time. Roentgen was not to discover X-rays until 1895, and plain X-rays of the spine are in any case of only limited help in the diagnosis and localisation of benign spinal tumours. Myelography, using radio-opaque contrast introduced into the dural sac, was introduced by Knuttson in Germany in 1944 and was a considerable advance in localising spinal tumours, but accurate diagnosis really awaited the invention of first CT and then magnetic resonance imaging in the 1970's.
Horsley was a remarkable man. He was born in London in 1857; his father was a distinguished artist. Victor became a medical student at University Hospital, London. He soon noticed that small quantities of alcohol affected his concentration while studying, became a total abstainer and, in later life, a staunch campaigner against the evils of drink. He qualified in 1881 with first class honours and the gold medal. After serving as house surgeon at UCH and a period of study in Germany, he was appointed surgical registrar and, at the early age of 28, was put on the staff of UCH as Assistant Surgeon. In addition to his clinical duties, Horsley was also appointed Professor and Superintendent at the Brown Institution, a well equipped research facility, where he carried out extensive animal studies of the effects of total thyroidectomy, and worked on Pasteur's method of treating rabies with material from the dried spinal cord of infected animals.
In 1885, following the report of a successful removal of a brain tumour by Rickman Godlee the previous year at the Hospital for Epilepsy, the staff at Queen Square decided that a surgeon was needed conversant with the new trends and Horsley was appointed Assistant Surgeon in 1886. The room set aside for his operating theatre was the ward's converted day room! Here his first operation was the successful removal of a vascular cerebral cortex scar in a young man with uncontrollable epilepsy following trauma.
At Queen Square Horsley carried out a wide range of surgery including cerebral and spinal tumours and abscesses, operations for trigeminal neuralgia, and peripheral nerve injuries. It is often said that Harvey Cushing of Boston was the father of neurosurgery; well, Cushing was still at school while Horsley, a rapid and extremely skilful surgeon, was developing many of these procedures! (Among his many contributions, he devised "Horsley's wax", still used today, to stop the bleeding from the cut bone ends of the skull).
With the outbreak of the Great War in 1914, Horsley, already a Territorial officer, applied for service. 1916 found him as consultant surgeon at the British General Hospital in Amara, Mesopotamia (now Iraq), in the fighting against the Turks. The conditions were awful that August, with day temperatures of 120F in the shade and supplies, including even water, inadequate. He was suddenly taken ill, developed hyper pyrexia and died within a few hours. Whether this was paratyphoid, rampant at the time, or sun stroke was not established. He was buried next day in the grounds of the hospital.
Professor Harold Ellis
Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London
No competing interests declared
Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.
Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication December 2010.
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